Inaccurate Medical Records and Documentation Discrepancies
Penalty
Fine: $16,149
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain accurate and consistent medical records for two residents. For one resident, a bed safety evaluation did not indicate the use of a floor mat, while both the care plan and physician orders documented a floor mat on the right side of the bed, and visual observation confirmed its presence. The floor mat intervention had been implemented following a post-fall event. For another resident, there was a discrepancy in gender identification between the West Virginia POST form, which listed the resident as female, and the MDS admission screening, which recorded the resident as male. These inconsistencies were identified during record review and staff interviews.